The “anatomic” view of the suprarenals in medical imaging

Summary Based on coordinates derived from three series of anatomic sections, the authors propose a view for tomographic investigation, applicable in MRI and ultrasound, which reconstructs the ideal image of the suprarenal gland in its quadrilateral as described by Testut. This anatomic view is 45° vertical and oblique, intermediate between the sagittal and frontal views, which it can advantageously replace. A new aspect of suprarenal tomography, recalling the image of a triskele, is described in the context of this view.

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L'incidence anatomique des surrénales en imagerie médicale

Résumé A partir de coordonnées relevées sur trois séries de coupes anatomiques, les auteurs ont imaginé une incidence d'exploration tomographique, utilisable en IRM et en échographie, qui restitue l'image idéale de la glande surrénale dans son quadrilatère décrit par Testut. Cette incidence anatomique est verticale et oblique à 45°, intermédiaire entre les incidences sagittale et frontale auxquelles elle se substitue avantageusement. Un aspect nouveau du tomogramme surrénalien, rappelant l'image d'un triskèle, est décrit à propos de cette incidence.

     

Terminology of the branches of the lateral circumflex femoral artery: Who is Who?

The anterolateral thigh flap and the tensor fasciae latae flap are supplied by the lateral circumflex femoral artery (LCFA). Different branching patterns of the LCFA have been described, leading to confusion, discrepancies and difficulties in clinical and cadaveric study comparisons. The aim of this study was to evaluate the branching patterns of the LCFA in dissected lower limbs and propose a simplified nomenclature. One hundred and two lower limbs fixed with Thiel's method were investigated. Meticulous dissection was performed, and the branching pattern of the arteries was documented by illustration and photography. These were analysed and allocated to the currently existing terminologies regarding the numbers of the branches (Part 1), and these subgroups were evaluated according to the variability of the trunk formations (Part 2). In Part 1, four subgroups could be classified (A, B, C and D). Group A included a total number of three branches (n = 50), Group B included four (n = 41), Group C included five (n = 5) and Group D included only two branches (n = 6). Part 2 showed in total 11 different trunk variations. Group A had four trunk variations: A1 (n = 38), A2 (n = 5), A3 (n = 2) and A4 (n = 6); Group B also had four variations: B1 (n = 16), B2 (n = 18), B3 (n = 3) and B4 (n = 4); Group C displayed two variations: C1 (n = 1) and C2 (n = 4); and in Group D, there was only one variation observed D1 (n = 6). Branching patterns were highly variable and inconsistent in terms of the number of branches and trunk variations, which resulted in different possible and justified interpretations and classifications. A new terminology should be defined cooperatively among anatomists and clinicians that will be useful for everybody. We propose a terminology oriented to the associated muscles.     

Tipping the balance towards tolerance: The basis for therapeutic immune modulation by gold?

Gold salts have long been used in the treatment of rheumatoid arthritis. However, the basis for their therapeutic immune-modulating properties has never been satisfactorily explained. Furthermore, treatments are often marred by the development of adverse immune reactions such as hypersensitivity and even exacerbation of autoimmunity. We would like to propose a hypothesis to explain the basis for both the beneficial and adverse immune-modulating effects of gold in the treatment of rheumatoid arthritis. If accepted, this hypothesis will allow for the development of safer and more effective treatments with gold salts. The principle underlying this hypothesis also has broader implications for how immune hypersensitivity and tolerance are perceived.     

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo’s flap): CT cadaver study

Objective

We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap.

Study design

We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients.

Methods

Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum.

Results

The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients.

Conclusion

The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

     

The posterior pedicled inferior turbinate–nasoseptal flap: a potential combined flap for skull base reconstruction

Objectives

To develop a combined pedicled flap comprising the mucoperiosteum and mucoperichondrium of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum based on the posterior lateral nasal artery, a branch of the sphenopalatine artery, for the reconstruction of skull base defects resulting from endoscopic expanded endonasal approaches.

Methods

Eleven fresh adult cadaver heads were dissected. Arterial distribution patterns of the inferior turbinate, lateral nasal wall, nasal floor, and nasal septum were investigated. The posterior pedicled inferior turbinate–nasoseptal flap was designed, measured, and harvested, and its ability to cover ventral skull base defects was examined.

Results

The inferior turbinate artery and/or posterior lateral nasal artery had 3.19 ± 1.47 (range 2–7) branches [mean outer diameter of largest branch, 0.40 ± 0.10 (range 0.24–0.60) mm] that anastomosed with the nasoseptal artery. These anastomosing arteries allowed the posterior lateral nasal artery to supply arterial blood to the nasoseptal mucoperichondrium and mucoperiosteum. Mean flap length was 100.65 ± 5.61 (range 91.43–109.44) mm, and minimum and maximum widths were 25.21 ± 2.29 (range 22.36–30.23) and 44.53 ± 5.02 (range 36.45–54.10) mm, respectively. Mean flap area was 3090.69 ± 288.08 (range 2612.97–3880.09) mm². The flap covered defects extending from the frontal sinus to the foramen magnum in all specimens.

Conclusions

Harvesting of a posterior pedicled inferior turbinate–nasoseptal flap is feasible. It should be considered a useful option for the reconstruction of large defects involving the anterior skull base, planum sphenoidale, sella turcica, and/or clivus.

     

Arterial anatomy of the lateral orbital and cheek region and arterial supply to the “peri-zygomatic perforator arteries” flap

Arterial anatomy of the lateral orbital and cheek region and subsequently of the “peri-zygomatic perforator arteries” flap is described, based upon the dissection of the 24 human cadaver head halves. Each specimen was dissected in subdermal, first fascial and deep level. The subdermal vascular network of lateral orbital and cheek region, its orientation and contributing arteries were studied. Origin, perforation sites and diameters of transverse facial, zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries were also described and measured. Our findings support the view that the cheek island flap used for lower eyelid is a reverse flow axial pattern flap. It includes arterioles of the transverse facial artery, which are part of the subdermal vascular plexus and are uniformly longitudinally oriented. The flap receives its blood supply via perforators of the zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries, which are connected via their terminal branches with transverse facial artery.     

Tipping the balance towards tolerance: the basis for therapeutic immune modulation by gold?

Gold salts have long been used in the treatment of rheumatoid arthritis. However, the basis for their therapeutic immune-modulating properties has never been satisfactorily explained. Furthermore, treatments are often marred by the development of adverse immune reactions such as hypersensitivity and even exacerbation of autoimmunity. We would like to propose a hypothesis to explain the basis for both the beneficial and adverse immune-modulating effects of gold in the treatment of rheumatoid arthritis. If accepted, this hypothesis will allow for the development of safer and more effective treatments with gold salts. The principle underlying this hypothesis also has broader implications for how immune hypersensitivity and tolerance are perceived.     

Anatomic basis for the treatment of aneurysms of the upper cervical segment of the internal carotid artery by extra- intracranial cervico-petrous bypass with inverted “in situ” saphenous vein graft

Summary In the surgical treatment of aneurysms of the upper cervical portion of the internal carotid a., exclusion of the affected vascular segment combined with an extra-anatomic cervico-petrous bypass using a vein graft (great saphenous v.) may be considered. One of the problems specific to these extra-anatomic bypasses is asociated with the sub-cutaneous positioning of the vein graft, exposing it to risks of angulation, torsion or extrinsic compression that may lead to early venous thrombosis. We suggest an alternative technique using the principle of telescoping and consisting of positioning the vein graft within the cervical portion of the artery (in situ bypass). The cervical portion of the ICA may be used as a tunnel for the vein graft since there are no collateral arterial branches at this level. The technical features of such a bypass are defined by means of an anatomo-surgical study in the cadaver: exposure of the petrous portion of the internal carotid a. in its horizontal segment by subtemporal access, exposure of the ICA in the neck, transverse arteriotomies of the ICA, angioplasty with a Fogarty balloon, intracarotid telescoping of a saphenous vein graft from the cervical to the petrous region, distal end-to-end anastomosis between the vein graft and the petrous portion of the ICA, and proximal end-to-end anastomosis between the vein graft and the cervical portion of the ICA.

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Pontage extra-intracrânien cervicopétreux par greffon veineux saphène inversé in situ dans le traitement des anévrismes de la partie cervicale haute de l'artère carotide interne (bases anatomiques, applications chirurgicales)

Résumé Dans le traitement chirurgical des anévrismes de la partie cervicale haute de l'a. carotide interne, un trapping du segment vasculaire pathologique associé à un pontage extra-anatomique cervico-pétreux utilisant un greffon veineux (grande v. saphène) peut être proposé. Un des problèmes spécifiques de ces pontages extra-anatomiques est lié au positionnement sous-cutané du greffon veineux exposant aux risques de coudure, torsion ou compression extrinsèque du greffon pouvant conduire à une thrombose veineuse précoce. Nous proposons une alternative technique utilisant le principe du télescopage et consistant à positionner le greffon veineux dans l'a. carotide interne cervicale (pontage in situ). La partie cervicale de l'a. carotide interne peut être proposée comme tunnel au greffon veineux compte-tenu de l'absence de branches collatérales artérielles. Les modalités techniques de ce pontage cervico-pétreux in situ sont précisées à partir d'une étude anatomo-chirurgicale chez le cadavre : exposition de la partie pétreuse de l'a. carotide interne dans sa portion horizontale par voie sous-temporale, exposition de la partie cervicale de l'a. carotide interne par cervicotomie, artériotomie transversale de l'artère carotide interne aux niveaux cervical et pétreux, angioplastie par ballonnet de Fogarty, télescopage intra-carotidien d'un greffon veineux saphène de la région cervicale à la région pétreuse, anastomose termino-terminale distale entre le greffon veineux et la partie pétreuse de l'a. carotide interne, anastomose terminoterminale proximale entre le greffon veineux et la partie cervicale de l'a. carotide interne.

     

A new anatomic trait for identifying the mendosal suture in young children: the mendosal–lambdoidal angle

Purpose

Radiologic diagnosis of skull fractures in young children is difficult due to numerous accessory sutures. This is especially true around the occipital bone because it has more than one ossification center. Normal anatomic variants, such as the mendosal suture, may be misinterpreted as a skull fracture. We investigated the anatomic traits of the mendosal suture in young children.

Methods

We retrospectively evaluated 52 children, aged between 1 month and 4 years, who had undergone head computed tomography with three-dimensional reconstructions. We evaluated the presence or absence of the mendosal suture. If present, then we measured the length of the suture and the angle between the lambdoidal and mendosal suture lines.

Results

The presence of the mendosal suture was bilateral in 12 children and unilateral in 5 children. The mendosal suture had a mean length of 13.9 ± 3.4 mm on the right side and 11.2 ± 4 mm on the left side. The angle between the mendosal and lambdoidal sutures had a mean value of 54.2° ± 11° for the right side and 53.6° ± 13.9° for the left side. The 95 % confidence interval for the mean value of the angle had a lower and upper bounds of 48° and 60° on the right side and 46° and 61° on the left side, respectively.

Conclusions

The angle between mendosal and lambdoidal suture lines may help radiologists to identify the mendosal suture.

     

Statin therapy for primary prevention in men: What is the role for coronary artery calcium?

Current cholesterol guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) base statin treatment decisions on multiple risk factor algorithms (e.g., Pooled Cohort Equations [PCEs]). By available PCEs, most older middle-aged men are statin eligible. But several studies cast doubt on predictive accuracy of available PCEs for ASCVD risk assessment. Recent studies suggest that accuracy can be improved by measurement of coronary artery calcium (CAC). This method has the advantage of identifying men at low risk in whom statin therapy can be delayed for several years, provided they are monitored periodically for progression of CAC. Thus, there are two approaches to statin therapy in men ≥ 55 years: first all men could be treated routinely, or second, treatment can be based on the extent of coronary calcium. The latter could allow a sizable fraction of men to avoid treatment for several years or indefinitely. Whether with initial CAC scan or with periodic rescanning, a CAC score ≥ 100 Agatston units is high enough to warrant statin therapy. In otherwise high-risk men (e.g., diabetes, severe hypercholesterolemia, 10-year risk by PCE ≥ 20%), a statin is generally indicated without the need for CAC; but in special cases, CAC measurement may aid in treatment decisions.     

Microbial biofilm growth vs. tissue integration: “The race for the surface” experimentally studied

Biomaterial-associated infections constitute a major clinical problem. Unfortunately, microorganisms are frequently introduced onto an implant surface during surgery and start the race for the surface before tissue integration can occur. So far, no method has been forwarded to study biofilm formation and tissue integration simultaneously. The aim of this study is to describe an in vitro method to investigate this “race for the surface”. First, a suitable growth medium was prepared that allowed both bacterial and tissue growth in a parallel plate flow chamber. Staphylococci were deposited on the glass bottom plate of the flow chamber in different surface densities, after which U2OS osteosarcoma cells were seeded. U2OS cells did not grow in the absence of flow, possibly due to poisoning by bacterial endotoxins, but under flow both staphylococci and U2OS cells grew. The number of adhering cells and area per spread cell were determined after 48 h in relation to the initial number of bacteria present. Both the number and spread area per cell decreased with increasing density of adhering staphylococci. This demonstrates that the outcome of the race for the surface between bacteria and tissue cells is dependent on the number of bacteria present prior to cell seeding.     

The organization of the conceptual system: The case of the “object versus action” dimension

There are very numerous reports in the neuropsychological literature of patients showing, in naming and/or comprehension tasks, a disproportionate deficit for nouns in comparison with verbs or a disproportionate deficit for verbs in comparison with nouns. A number of authors advanced that, in at least some or even in every of these reported cases, the noun/verb dissociation in fact reflected an underlying conceptual deficit disproportionately affecting either object or action concepts. These patterns thus would put an additional constraint on theories of conceptual knowledge organization, which should be able to explain how brain damage could selectively disrupt the concepts of objects or the concepts of actions. We have reviewed 69 papers (published from 1984 to 2009) that reported a pattern of a noun or a verb disproportionate deficit in a single-case, multiple-case, or group study of brain-damaged patients with various aetiologies. From this review, we concluded that none of these studies provided compelling evidence in favour of the interpretation that the observed noun or verb disproportionate deficit arose at the conceptual processing level and, accordingly, that this level may be organized according to the “object/action” dimension. Furthermore, we argue that investigating conceptual impairments in brain-damaged patients according to the “object/action” dichotomy is not empirically fruitful if the purpose is to inform theories of conceptual knowledge organization. In order to provide evidence relevant to these theories, one needs to consider finer grained distinctions within both the object and the action category when investigating the scope of the patients' conceptual impairment.     

Superficial temporal artery: the “C” shape half-buttonhole configuration as it courses over the zygomatic arch

Purpose

To describe the course and configuration of the superficial temporal artery (STA) around the zygomatic arch.

Methods

Volume rendered 3D reconstructions of computed tomography angiography of 25 healthy patients were performed and analyzed at Duke University Hospitals.

Results

The STA coursed over the zygomatic arch or over the condylar process of the mandible in all cases (25/25 pts, 100 %). The STA courses over the posterior zygomatic arch in 23/25 pts (92 %), creating a characteristic “C” shape half-buttonhole configuration as it embraces the arch. When the STA travels posterior to the zygomatic arch, there is no C shape configuration (2/25 pts, 8 %). The STA bifurcates distal to the zygomatic arch in 24/25 pts (96 %).

Conclusions

The “C” shape half-buttonhole configuration is a useful identifying characteristic of the most common course of the STA—over the posterior zygomatic arch before it bifurcates.

     

The underlying mechanisms for the “simultaneous HBsAg and anti-HBs serological profile”

The course of HBV infection is determined by the interplay between viral replication via HBV protein production and the host’s immune response. Therefore, the diagnosis of infection in clinical practice is established by the serological detection of HBV protein products as well as antibodies produced by the host. Although the serological findings for assessing the clinical course of infection are already well established, the expression of viral proteins and the dynamics of antibody production may vary during the natural course of infection. This causes the HBV infection to be occasionally associated with the presence of unusual serologic profiles, which can lead to doubts in the interpretation of results and mistaken serological diagnosis. The simultaneous detection of HBsAg and anti-HBs in the blood stream comprises an atypical serological profile, somewhat incoherent, whose significance can be complicated to establish. Outlined in this article are some immunological and molecular mechanisms which could justify the existence of this profile in which there is a great laboratorial and clinical interest.